Maternity and Peds: 13 Adaptations to Pregnancy

Result of increase in vascularity in vagina during pregnancy

> A bluish color (as in Chadwick's sign), thickening of vaginal mucosa, prominence of rugae, heightened sexual interest

Multigravida

> A woman who has been pregnant more than once

Amenorrhea

> Absence of menstruation

Cause of Chadwick's sign in the cervix

> Cause is hyperemia, and it is a bluish color that extends to the vagina and labia

Cause of Goodwell's sign in the cervix

> Cervical, uterine, and vaginal softening with increased vascularity and softening of the connective tissue

Role Transition

> Changing from one pattern of behavior or another

Plasma Volume

> Non-pregnancy level: 34.77 ± 3.24 > Pregnancy Level: 1200- 1600 mL > Change: Increase of 40-60% above non pregnant values

Cause of Mucous plug in the cervix

> Plug caused by increased secretion of mucous from cervical glands that blocks ascent of bacteria from the vagina

Why is progesterone essential in pregnancy?

> Pregnancy cannot be maintained without progesterone

Couvade

> Pregnancy- related rituals experienced by some prospective fathers

Narcissism

> Preocupation with self

Cardiovascular System: Heart

> Reversible after birth > The heart is pushed upward and toward the left as the uterus elevates the diaphragm during the third trimester > Heart Sounds: The most common variations in heart sounds include splitting of the first heart sound and a third heart sound.

How might sexual interest and activity change during pregnancy? What factors may increase or decrease interest in either partner of the couple?

> Sexual interest and activity may be heightened or reduced. The woman may be more responsive because pelvic vasocongestion heightens sensitivity and lubricates the vaginal area. Fear of miscarriage, harming the fetus, or causing discomfort may suppress sexual desire in either partner. The woman may feel less attractive, or her partner may find her less attractive at this time.

Why does the pregnant woman's bone mass stay stable even though the fetus requires calcium for skeleton development?

> The amount of calcium transferred to the fetus is small in com- parison with maternal stores, and there is no loss of maternal bone density to supply fetal needs.

A pregnant woman complains that both of her thumbs hurt at times. Neither thumb is inflamed or discolored. The nurse should explain to the woman that: a. she probably injured her hand and does not recall doing so b. an undiagnosed fracture may have healed improperly c. osteoarthritis often has its onset during pregnancy d. increased tissue fluid is causing compression of a nerve

D

A pregnant woman expects to give birth to her first baby in approx 1 week. She asks the nurse whether she has a bladder infection because she urinates so much, even though urination causes no discomfort. The nurse should explain to her that: a. UTI are most common just before birth, so she should have a urine specimen tested b. Her fetus is probably lower in her pelvis, putting more pressure on her bladder c. limiting her fluid can reduce the number of times she must interrupt her activity to urinate d. The fetal growth has probably stopped and she should expect to start labor in a few days

B

A pregnant woman is prone to UTI primarily because: a. a large volume of fetal wastes must be excreted by her kidneys b. urine stasis allows additional time for the bacteria to multiply c. the volume of urine excreted is reduced and its specific gravity is high d. reduced blood flow to the urinary tract allows waste to accumulate

B

A woman having physiologic anemia of pregnancy has hemoglobin and hematocrit levels of at least: a. 10g/dl and 30% b. 10.5 g/dl and 33% c. 11 g/dl and 35% d. 12 g/dl and 38%

B

A woman who is 12 weeks pregnant begins wearing maternity clothes. This is most likely an example of: a. introversion b. mimicry c. narcissism d. fantasy

B

Fundus is at xiphoid process

36 weeks

Uterus can be first palpated above the symphysis pubis in

12 weeks

Fundus can be palpated about halfway between symphysis pubis and umbilicus

16 weeks

Fundus is at level of umbilicus

20 weeks

Describe changes in maternal heart sounds that may occur during pregnancy. When do the heart sound changes occur? Describe common changes in heart sounds

> Changing in heart sounds begin between 12 and 20 weeks and regress during the first week after childbirth. They may include splitting of the first heart sound and a systolic murmur. Murmur may persist beyond 4th week.

Ambivalence

> Conflicting emotions

Mimicry

> Copying the behaviors of others

What breast changes occur during pregnancy?

> Darkening of the areolae, increasing nipple and areolae size, areolae become more erect, Montgomery's tubercules become prominent

Describe edema that is expected during pregnancy and why it occurs. When should it be reported?

> Edema of the legs and feet is not uncommon. Edema above the waist (face and fingers) may be an indication of pregnancy induced hypertension and should be reported.

Reproductive Stystem: Cervix

> Estrogen causes hyperemia (congestion with blood): results in the bluish purple color that extends to include the vagina and labia. > Chadwick's sign: One of the earliest signs of pregnancy (purple discoloration of cervix) > Goodell's sign: Collagen fibers in the connective tissue of the cervix decrease causing the cervix to soften. > One of the earliest sign of labor "bloody show": Mucous plug plus a small amount of blood.

Reproductive Stystem: Breasts

> Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. > The nipples increase in size and become darker and more erect, and the areolae become larger and more pigmented. > Sebaceous glands, called tubercles of Montgomery, become more prominent during pregnancy and secrete a substance that lubricates the nipples. > A thick, yellowish fluid (colostrum) is present beginning at 12 to 16 weeks of pregnancy and can readily be expressed from the breasts by the third trimester > Secretion of milk is suppressed during pregnancy by high levels of estrogen and progesterone.

Hyperemia

> Excess of blood in a part of of the body

Chloasma

> Facial pigmentation

Physiologic anemia of pregnancy

> Fall in hematocrit that occurs because plasma volume expends more than rbc volume

Reproductive Stystem: Uterus

> Full term: 1100 - 1200 gram; capacity of 5000 mL > First trimester: Mainly a result of hyperplasia caused by stimulation from estrogen and growth factors > Second and third trimester: Growth is caused by hyperplasia and hypertrophy as muscle fibers stretch

At what point in gestation is it possible to hear fetal heart sounds using a Doppler?

> Gestational age 9 weeks

Result of growth of connective tissue in vagina during pregnancy

> Greater pliability and distensibility

Why might grief have a place during a desired normal pregnancy?

> Grief may be caused by feelings or giving up life as a carefree woman and loss of spontaneity to go to places and do things.

What changes occur that could make the fetus seem real to the pregnant woman?

> Increase in uterine size, weight gain, breast changes, fetal movements (quickening)

Result of secretion of increased amounts of glycogen in vagina during pregnancy

> Increased acidic vaginal charge that retards growth of bacteria but favors growth of Candida Albicans (yeast)

Why does pregnancy induced change in fibrinogen levels have a protective effect yet also increase risk?

> Increased fibrinogen levels offer protection from excess blood loss but also predispose woman to thrombus formation

Introversion

> Inward concentration

Reproductive Stystem: Braxton Hicks contractions

> Irregular contractions > During first two trimesters contractions occur more frequently and causes some discomfort > Called false labor

Striae gravidarum

> Irregular reddish streaks caused by tears in connective tissue " stretch marks"

What is the significance of quickening in the woman's developing relationship with her fetus?

> It makes the fetus much more like a separate being rather than a part of the woman's body.

What is "supine hypertensive syndrome"? What signs and symptoms might a woman with this syndrome display? What should the nurse do to prevent or relieve it?

> Lying in the supine position places the heavy uterus over the aorta and inferior vena cava, which temporarily occludes these vessels. > Signs and symptoms include faintness, lightheadedness, dizziness, agitation, and sometimes brief unconsciousness. This position can reduce placental blood flow (fetal hypoxia). > Prevention/ treatment is to position the woman on her side or with a pillow under one hip.

Reproductive Stystem: Ovaries

> Major function of the ovaries is to secrete progesterone from the corpus luteum for the first 6-7 weeks of pregnancy > Progesterone is called the hormone of pregnancy because adequate progesterone must be available from the earliest stages, if pregnancy is to be maintained. > Corpus luteum secretes progesterone until placenta is developed > Once developed the placenta produces progesterone throughout the pregnancy > Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) necessary for ovulation.

Cause of Bloody Show in the cervix

> Mixture of cervical mucus and a small amount of blood; disruption of mucous plug and small capillaries of cervix

Leukocytes Leukocytes increase during pregnancy, ranging from 5000 to 12,000 cells/mm3 to as high as 15,000 cells/mm3. Leukocytes increase further during labor and the early postpartum period, reaching 25,000 to 30,000 cells/mm3.

> Non- pregnancy level: > Pregnancy level: > Change:

Fibrinogen

> Non- pregnancy level: 200-400 mg/dL > Pregnancy level: 300-600 g/dL > Change:

RBC Volume

> Non- pregnancy level: 4.2-5.4 million/mm^3 > Pregnancy level: 3.8 - 4.4 million/ mm^3 > Change: Decreases slightly because of hemodilution

What changes in carbohydrate metabolism and in production, utilization, and breakdown of insulin occur during pregnancy? Why do the changes occur? How does the woman's body normally respond to these changes?

> The fetus draws on maternal glucose and amino acids, which reduces the mother's glucose levels and her ability to synthesize glucose. > During the first trimester, the lower maternal blood glucose causes the pancreas to secrete less insulin. > During the second trimester, hormones (human placental lactogen, prolactin, progesterone, and cortisol) reduce the maternal tissue sensitivity to insulin. Thus the mother's blood glucose level rise to make more available for the fetus. The woman normally responds by increasing insulin production.

Why are pregnant women more likely to develop gallstones?

> The gallbladder becomes hypotonic and emptying time is prolonged, resulting in thicker bile and predisposing to the development of gallstones.

What two factors contribute to a woman's sense of dyspnea?

> The growing uterus eventually lifts the diaphragm and reduces lung expansion. > Because the respiratory center becomes more sensitive to carbon dioxide, the minute volume increases and the partial pressure of carbon dioxide falls.

Why does ovulation cease during pregnancy?

> The high levels of estrogen and progesterone inhibit follicle stimulating hormone (FSH) and luteinizing hormone (LH)

Blood Volume

> Total blood volume increases by as much as 45%. Consists of plasma, RBC's, WBC's, Erythrocytes, and platelets

Reproductive Stystem: Vagina and Vulva

> Vaginal mucosa thickens and vaginal rugae become very prominent > PH of vaginal discharge is acidic because of increased production of lactic acid that results from lactobacillus acidophilus on glycogen in the vaginal epithelium. > However the glycogen rich environment favors the growth of Candida Albicans so persistent yeast infections are common during pregnancy.

What nasal changes are common during pregnancy? What causes them?

> Vasocongestion from estrogen's effects causes increased vascularity and edema, leading to nasal stiffness, nose bleeds, and voice changes. It may also result in ear fullness or earaches.

Progesterone is produced first by the _____ and then by the _____

> corpus luteum; placenta

List some reasons for a false-negative pregnancy test

>Incorrect procedure >Testing too early >Urine too dilute >Certain medications (diuretics, anticonvulsants, antiparkinsonian, hypnotics, and tranquilizers) >Hematuria >Proteinuria >Malignant tumors that produce hCG (causes a positive pregnancy result)

Why is pregnancy risk assessment not a one time evaluation?

>Later in the pregnancy, risk factors may appear that were not apparent at previous assessments.

List the presumptive, probable, and positive indications of pregnancy. What is the difference among the three classifications?

>Presumptive: some signs are amenorrhea, nausea, vomiting, fatigue, urinary frequency, breast and skin changes. >Probable: Some signs are abdominal enlargement, cervical softening, ballottement, Braxton-Hicks contractions, pregnancy test. > Positive: Fetal heart sounds, fetal movements felt by the examiner, visualization of fetus. >The difference among the indications is that presumptive indicators are least reliable because they are often caused by other conditions; probably indicators are stronger evidence but still may have other causes; positive indicators are those caused only by pregnancy.

What routine urine testing is performed during prenatal visits?

>Protein: May be present but amt should not increase, presence may indicate contamination by vaginal secretions, kidney disease, or preeclampsia. >Glucose: Small amts may indicate physiologic "spilling" that occurs during normal pregnancy. >Ketones: May be found after heavy exercise or as a result of inadequate intake of food or fluid.

Use Nagele's rule to calculate estimated dates of delivery for each of these dates representing last normal menstrual period dates: a. February 4 b. August 2

>Rule: Subtract 3 months from the first day of the last normal menstrual period, add 7 days, and correct the year a. November 11 b. May 9

A pregnant woman has a blood glucose screening at 26 weeks of gestation. The result is 128 mg/dl. The nurse should expect that: a. no additional glucose testing will be needed b. insulin injections will be needed by 30 weeks of gestation c. oral drugs may be prescribed to lower her glucose level d. more testing is needed to determine additional therapy

A

The nurse can best help a man assume his role as a parent by: a. Encouraging him to ask questions about his partner's pregnancy b. Referring him to prenatal discussion groups for expectant fathers c. Advising the woman to limit discussions of her symptoms during early pregnancy d. Enrolling him in childbirth classes to involve him actively in the birth

A

The primary benefit of preconception class is to: a. Reduce the risk of having a baby with a birth defect b. Begin the pregnancy in an optimal nutritional state c. Limit the number of unplanned pregnancies in the community d. Encourage the couple to have their baby at the facility

A

Choose the maternal behavior that best describes role playing during pregnancy. a. The woman shifts from saying "I am pregnant" to "I am having a baby" b. The woman begins calling her fetus by a name rather than "it" c. The woman tries to care for infants while an experienced mother watches d. The woman becomes less absorbed in her own needs and focuses on the fetus

C

The primary benefit of perinatal education is to help: a. Reduce the likelihood that parents will have problems with their infants b. Women have a satisfying, medication- free childbirth c. Parents become active in health maintenance during pregnancy and birth D. Enhance the chance that prospective parents will return to a hospital

C

Choose the most likely reaction of an 8-year-old to his mother's pregnancy. a. Embarrassment or shame at his mother's appearance b. Inability to sense the reality of the infant c. Desire to role play his big brother status d. Interest in learning about the developing baby

D

Slight respiratory alkalosis during pregnancy enhances: a. growth of fetal arteries within the placenta b. the fall in systolic and diastolic bp c. maternal metabolism of food and nutrients d. transfer of fetal CO2 to maternal blood

D

The nurse is teaching a Laotian woman about self-care during pregnancy. The nurse can best determine whether she learned the information by: a. Asking the woman to indicate what teaching she did and did not understand b. Observing for the woman's eye contact with the nurse during teaching c. Recognizing that nodding while being taught indicates understanding d. Having the woman restate the information that is taught

D

List the typical maternal responses for each trimester of pregnancy. a. 1st b. 2nd c. 3rd

a. Anxious to find confirmation of pregnancy, ambivalence, focus on self b. Physical evidence of pregnancy, focus on fetus, narcissism, introversion, body image, sexual interest c. Feelings of vulnerability replaced by coming to terms with the situation, fantasies or nightmares, increased dependence, desire to see the baby, dread about labor or being anxious for the pregnancy to end

Describe 3 developmental processes that the expectant father goes through during pregnancy.

a. Grappling with reality of pregnancy and a new child b. Struggling for recognition as a parent c. Desire to be seen as relevant to the childbearing process

Describe the 4 normal tasks of pregnancy, according to Rubin.

a. Seeking safe passage for herself and baby b. Securing acceptance of herself and baby c. Learning to give to herself D. Developing attachment to unknown child

Describe significant maternal changes that occur in a multifetal pregnancy: a. Blood volume b. Cardiac workload c. Respiratory workload d. Blood vessel compression e. Bowels

a. There is a 500 mL increase in blood volume b. Cardiac workload is higher because of increased blood volume C. Greater diaphragm elevation increases dyspnea D. Greater compression of aorta and inferior vena cava causes earlier and more pronounced supine hypertension E. Pressure on bowels increase constipation

How do each of the following differ when a woman has a multifetal pregnancy? a. Uterine size b. Fetal movements c. Weight gain

a. Uterine size is larger than expected b. Fetal movements are more numerous c. Greater weight gain occurs because of greater uterine growth, increased blood volume and amniotic fluid, and presence of two or more fetuses.